Screening for Bladder Cancer
Routine screening for bladder cancer in asymptomatic adults is not recommended, as there is insufficient evidence that screening improves mortality or morbidity outcomes, and the potential harms—including false positives, unnecessary cystoscopies, overdiagnosis, and anxiety—outweigh uncertain benefits. 1
Evidence Against Routine Screening
The U.S. Preventive Services Task Force (USPSTF) assigns a Grade I recommendation (insufficient evidence) for bladder cancer screening in asymptomatic adults, meaning the balance of benefits and harms cannot be determined even in populations at elevated risk. 1, 2 This recommendation applies to all asymptomatic adults, including those with occupational exposures to chemicals such as benzenes and aromatic amines. 2
Key reasons screening is not recommended:
- No mortality benefit demonstrated: No randomized trials or high-quality observational studies show that screening reduces bladder cancer deaths compared to symptom-based detection. 1, 3
- Low positive predictive value: Even in high-risk populations (smokers, occupational exposures), screening tests have a positive predictive value below 10%, meaning more than 90% of positive results are false positives. 3
- Substantial harms: False-positive results lead to unnecessary cystoscopies with risks of bladder perforation, bleeding, infection, and significant patient anxiety. 1, 2
- Overdiagnosis risk: Approximately 70% of bladder cancers are superficial (Ta or T1) tumors that may never progress to life-threatening disease, yet screening would subject these patients to invasive procedures and treatments. 2
What Primary Care Clinicians Should NOT Do
Do not perform routine urinalysis with the primary intent of screening for bladder cancer in asymptomatic adults. 1 While urinalysis may be ordered for other clinical indications (proteinuria, glycosuria), using it specifically to detect occult hematuria as a cancer screening tool lacks evidence of benefit. 1
Do not use urine-based biomarkers (NMP22, cytology, molecular markers) for screening asymptomatic individuals. 1, 4 A study of 1,502 high-risk asymptomatic individuals screened with NMP22 BladderChek found only 3 cases of bladder cancer (0.2% prevalence), with a 5.7% false-positive rate requiring unnecessary cystoscopies. 4
Evaluation of High-Risk Individuals with Hematuria
While screening is not recommended, any patient who develops hematuria requires prompt and complete evaluation regardless of risk factors. 1 This is symptom-based evaluation, not screening.
Confirming True Hematuria
Before initiating any workup, confirm hematuria with microscopic urinalysis showing ≥3 red blood cells per high-power field (RBC/HPF) on at least two of three properly collected clean-catch midstream urine specimens. 1, 5 Dipstick testing alone has only 65-99% specificity and produces false positives from myoglobin, hemoglobin, oxidizing contaminants, and menstrual contamination. 1, 5
Gross Hematuria: Urgent Evaluation Required
All adults with gross (visible) hematuria require urgent urologic referral for cystoscopy and upper tract imaging, even if bleeding is self-limited. 1, 5 Gross hematuria carries a 30-40% risk of malignancy and should never be dismissed. 1, 5, 6
Do not attribute gross hematuria to anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves. 1, 5 Evaluation must proceed regardless of medication use. 1
Microscopic Hematuria: Risk-Stratified Approach
For confirmed microscopic hematuria (≥3 RBC/HPF), the American Urological Association (AUA) recommends risk stratification based on: 5
High-risk features requiring complete urologic evaluation (cystoscopy + CT urography):
- Age ≥60 years (men) or ≥60 years (women) 5
- Smoking history >30 pack-years 5
- Any history of gross hematuria 5
- Occupational exposure to benzenes, aromatic amines, or other bladder carcinogens 1, 5
- Irritative voiding symptoms (urgency, frequency, dysuria) without documented infection 5, 7
- Degree of hematuria >25 RBC/HPF 5
Intermediate-risk features (shared decision-making about cystoscopy/imaging):
- Age 40-59 years (men) or age ≥60 years with lower-risk features (women) 5
- Smoking history 10-30 pack-years 5
Low-risk features (may defer extensive imaging):
Excluding Benign Causes Before Proceeding
If urinary tract infection is suspected (pyuria, symptoms), obtain urine culture and treat appropriately. Repeat urinalysis 6 weeks after treatment—if hematuria resolves, no further evaluation is needed. If hematuria persists, proceed with full urologic evaluation. 5, 7
Transient benign causes to exclude (repeat urinalysis 48 hours after cessation): 5
- Vigorous exercise within 24-48 hours
- Sexual activity
- Menstruation (obtain catheterized specimen if contamination suspected)
- Viral illness
If hematuria resolves after eliminating these causes, no further workup is needed. 5
Complete Urologic Evaluation Components
For patients requiring evaluation based on risk stratification:
Upper tract imaging: Multiphasic CT urography is the preferred modality, providing unenhanced, nephrographic, and excretory phases to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 5, 7 Renal ultrasound alone is insufficient for comprehensive evaluation. 5
Lower tract evaluation: Flexible cystoscopy is mandatory for high-risk patients to visualize bladder mucosa, urethra, and ureteral orifices. 5, 7 Flexible cystoscopy causes less pain than rigid cystoscopy with equivalent diagnostic accuracy. 5
Urine cytology: Consider in high-risk patients (age >60, smoking history, occupational exposures) as an adjunct to cystoscopy, particularly for detecting high-grade tumors and carcinoma in situ. 5, 7 However, do not obtain cytology or molecular markers as the initial evaluation tool. 1
Distinguishing Glomerular from Urologic Causes
Examine urinary sediment for: 5
- Dysmorphic RBCs (>80% suggests glomerular origin)
- Red blood cell casts (pathognomonic for glomerular disease)
- Significant proteinuria (spot protein-to-creatinine ratio >0.5 g/g)
If glomerular features are present (tea-colored urine, significant proteinuria, dysmorphic RBCs, elevated creatinine), refer to nephrology in addition to completing urologic evaluation—malignancy can coexist with medical renal disease. 5, 7
Follow-Up for Negative Initial Evaluation
If complete evaluation is negative but hematuria persists, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 5, 7 After two consecutive negative annual urinalyses, no further testing is necessary. 5
Immediate re-evaluation is warranted if: 5, 7
- Gross hematuria develops
- Significant increase in degree of microscopic hematuria
- New urologic symptoms appear
- Development of hypertension, proteinuria, or evidence of glomerular bleeding
Common Pitfalls to Avoid
Never ignore gross hematuria, even if self-limited—30-40% malignancy risk mandates urgent evaluation. 1, 5
Do not defer evaluation due to anticoagulation—these medications unmask rather than cause hematuria. 1, 5
Do not rely solely on dipstick testing—confirm with microscopic examination before initiating workup. 1, 5
Do not assume benign prostatic hyperplasia explains hematuria in older men—BPH can coexist with bladder cancer and does not exclude malignancy. 5
Do not prescribe empiric antibiotics for hematuria without documented infection—this delays cancer diagnosis and provides false reassurance. 5